Fungating Malignancies: Management of a Distinct Wound Entity
ABSTRACT
Objective: To address the literature gap on malignant fungating wound treatment by reporting two institutions’ experiences with this disease process and proposing practices to improve care.
Methods: A multi-institutional retrospective review was conducted of 44 patients with 45 malignant fungating wounds over an 11 year period. Patient characteristics, treatment history, and outcomes were analyzed.
Results: Of the 44 patients who met inclusion criteria, 31 patients (70.5%) were female while 13 patients (29.5%) were male. The average age at presentation was 63.0 ± 16.1 years old. The most common malignancy was breast cancer, accounting for over half of cases (54.5%). The average surface area of the tumors at presentation was 110.3 ± 215.0 cm2 (range 2.2–1140 cm2) while the average surface area at time of discharge/death was 104.6 ± 310.7 cm2 (range 0–1800 cm2). By Student’s t-test, neither surface area at presentation (p=0.504) nor surface area at time of final follow-up (p=0.472) were significantly associated with death during the study timeframe.
Conclusion: In the era of advancing technologies and medical innovation, the benefits of palliative surgery, that helps mitigate an open wound, should not be overlooked. Improving end of life care is beneficial to the patient and families alike. As surgeons, we strive for a tangible cure, but providing palliative resection to allow for death with dignity might be the most humane service of all.
Keywords: fungating wound; cancer; malignancy; palliative resection; wound care; plastic surgery
INTRODUCTION
Solid tumors have a variety of presentations, ranging from small indolent lesions to rapidly progressive masses. Despite advances in screening modalities and treatment regimens, patients may present in late-stage disease with malignant fungating wounds. These lesions are the result of erosive enlarging malignancies emanating from a deeper tissue plane causing overlying skin necrosis and bleeding.1,2 Necrotic material, blood, and copious exudate accumulate in deep crypts between friable tumor fronds, conferring risk for superimposed infection.1,3,4 Patients may delay presentation until home wound care has become unmanageable and they seek additional resources4; moreover, some patients present in a delayed fashion after initially seeking holistic treatments for their malignancy.9
Malignant fungating wounds are a poor prognostic sign, and many patients have been deemed unresectable given extensive disease. Although regarded as rare, malignant fungating wounds occur with a frequency of 5–14.5% in the terminal phase of advanced cancers.1,2,6–11 Symptoms of these wounds include malodor, local pain, mass effects, excessive exudate, intermittent bleeding, moisture-associated skin damage, local skin necrosis, and infection.1,6,7 Patients with fungating masses may resort to social isolation given these distressing symptoms.1,4,8 Further, complicated treatment protocols, including frequent dressing changes, can be time-consuming and cause strain on relationships between patients and family members/caregivers.1,3,8,9,13,14 These resultant psychosocial and physically challenging stressors negatively impact patients’ quality of life, further increasing suffering in the terminal phase of cancer.
The treatment of fungating tumors deviates from that of chronic wounds with non-malignant etiologies. While ample literature discusses care of chronic wounds, there is a paucity of reports focused on malignant fungating wounds, for which care is generally palliative.1,2–4,7–10,12,,15–17 Here, we address this gap by reporting on our experience managing malignant fungating wounds and propose the recognition of these wounds as distinct entities in the spectrum of chronic wounds. Ultimately, we advocate for the consideration of palliative surgical intervention of malignant fungating wounds if it will improve patients’ quality of life in end-stage disease.
METHODS
A multi-institutional Institutional Review Board (IRB)-approved retrospective review was performed on patients diagnosed with malignant fungating wounds managed by Plastic and Reconstructive Surgery between 2010–2021. All study procedures were conducted in accordance with the Declaration of Helsinki.
Inclusion criteria specified patients with fungating wounds emanating from a malignant etiology. Patients with clinically similar chronic wounds without proven malignancy were excluded. The results yielded 45 wounds across 44 patients. Patient medical history, demographics, photographs, pathology, referral basis surgical history, wound care treatment regimens, follow-up, and outcomes were reviewed.
Significant associations between variables were calculated with independent Student’s t-tests and chi-square tests; statistically significant p-values reflect an alpha (α) value <0.05. Descriptive statistics and significance testing were performed on SPSS Statistics 28.0.
RESULTS
Of the 44 patients who met inclusion criteria, 31 patients (70.5%) were female while 13 patients (29.5%) were male. At the time of the study’s completion, 15 patients (34%) were alive, 21 patients (48%) were deceased, and the outcomes of eight patients (18%) were unknown as they were lost to follow-up. The average age at initial cancer diagnosis was 58.7 ± 16.0 years old, and the average age at presentation to Plastic Surgery was 63.0 ± 16.1 years old (Table 1). Most patients presented after online searches for providers (n=16, 36.4%) followed by Oncologist referral (n=13, 29.5%), other physician referral (n=10, 22.7%), family/friends (n=2, 4.5%), self referral (n=1, 2.3%), and dental referral (n=1, 2.3%) with two unknown referral sources (4.5%). One patient presented with two fungating wounds, each of distinct etiology, resulting in a total cohort of 45 wounds (Supplementary Digital Content 1). The most common malignancy was breast cancer, accounting for over half of cases (n=24; 54.5%); (Figure 1 and Figure 2). Squamous cell carcinoma (SCC) was the second most common fungating malignancy encountered (n=11, 25.0%); of note, 34.1% of patients (n=15) suffered from skin cancers (melanoma, SCC, and basal cell carcinomas).
Regarding patients’ treatment history, 18 patients (40.9%) delayed seeking medical treatment and 13 patients (29.5%) attempted alternative therapies prior to consultation with Plastic Surgery. Average stage at presentation was 3.3. Eighteen patients (40.9%) received radiation therapy and 20 patients (45.5%) received chemotherapy (Table 2). The average time between diagnosis and surgical resection was 4.1 ± 5.8 years, and the average time between tumor ulceration and surgical resection was 3.6 ± 5.1 years. Chi-squared analysis demonstrated that radiation therapy trended towards being significantly associated with a final outcome of death (p=0.055) while no significant correlation with death was identified in those who received chemotherapy (p=0.152); however, these metrics may be reflective of overall disease stage and treatment paradigm for each pathology.
The average surface area of the tumors at presentation was 110.3 ± 215.0 cm2 (range 2.2–1140 cm2) while the average surface area at time of discharge/death was 104.6 ± 310.7 cm2 (range 0–1800 cm2). By Student’s t-test, neither surface area at presentation (p=0.504) nor surface area at time of final follow-up (p=0.472) were significantly associated with death during the study timeframe. Surface area at presentation was not significantly correlated with length of time between initial visit and death (p=0.564).
Patients were treated for an average of 24.1 ± 46.5 visits, with the duration of treatment ranging from one office visit to five years of care; nine patients (20.5%) were seen five times or less, of which two patients (4.5%) were only seen for one consultation; all nine patients were lost to follow-up. Debridement and/or debulking procedures were performed on 42 patients (95.5%); more specifically, debridement was performed both in the clinic as well as in the operating room. Biologics were used on 17 patients (38.6%), most commonly PuraPly (antimicrobial collagen wound matrix, Organogenesis, Canton, Massachusetts) and Oasis Matrix (porcine-derived extracellular matrix, Smith+Nephew, Memphis, Tennessee). The average time from initial Plastic Surgery visit to death was 1.3 years, ranging from 2 months to 5 years.
Presenting symptoms and reasons for seeking care include pain, excessive exudate, mass effects, malodor, moisture-associated skin damage, intermittent bleeding, local tissue necrosis, infection, and patient-reported adverse quality of life (Table 3). All patients experienced at least one symptom, with an average of five symptoms reported per patient. A typical constellation of symptoms included excessive exudate, reported by 39 patients (88.6%), pain (n=36; 81.8%), intermittent bleeding (n=32; 72.7%), malodor (n=31; 70.5%), and necrosis (n=30; 68.2%).
DISCUSSION
Even though operations for patients with malignant fungating wounds may not augment survival, surgical interventions such as mass excision, debridement, and possible reconstruction may improve quality of life by mitigating the effects of an open wound during the terminal phases of cancer. Palliative resection may not only ameliorate wound care but also help patients die with dignity and ease suffering of living out their days with foul smelling weeping wounds. This is of particular importance in the pediatric population with malodorous, ulcerating, and disfiguring wounds (Figure 3). Operative goals are to provide palliative resection and/or reconstruction with short operative time, acceptable risk, and low donor site morbidity while allowing for uncomplicated recovery.
In our cohort of 45 malignant wounds, the most common underlying etiologies were breast cancer, sarcomas, and skin cancer. Notably, over half of our patients were women with a fungating breast malignancy. This anatomic distribution is akin to other published reports.1,4,7,8,10 Our mean survival of 1.3 years after presentation is also comparable to other reports.4,11,12 Of interest, four outlier cases (9.3%) demonstrated long-term survival following complete resection: a locally advanced invasive ductal carcinoma of the breast, an ulcerated melanoma of the cheek, a fungating liposarcoma of the thigh, and an invasive squamous cell carcinoma of the fingertip. All four patients are still alive without evidence of disease >1 year post-resection. Although a small percentage of our cohort, these cases underscore that malignant fungating wounds deserve evaluation for resectability before a palliative path is charted.
Given our experience with malignant fungating wounds, we advocate for their treatment as a distinct entity from chronic wounds. Malignant fungating wounds present most commonly in the breast, head, and neck as rapidly growing malignant cells invading normal dermal architecture.1,4,7,8,10 The phenomena of local lymphedema, mass effects, tumor necrosis, and bacterial overgrowth in deep tumor crypts are processes not observed in wounds of benign etiology. Malignant fungating wounds are often large at presentation to Plastic Surgery or wound care, as reflected in our cohort with an average size of 110 cm2 at consultation. All patients presented with one or more wound-related symptoms, typically copious exudate and local pain, consistent with prior publications;1,6,7 44% of patients presented with all four of the most common symptoms: exudate, bleeding, pain, and malodor. Malodor is often the most distressing symptom as it can inhibit social interaction with family, friends, and even professional caregivers.1,3,5,8,9,13,14
The psychosocial characteristics of patients with malignant fungating wounds are also distinct from that of chronic wounds. Patients may exhibit a remarkable level of denial and dissociation from their disease. In addition, the incidence of malignant fungating wounds is linked to the onset of anxiety, depression, and personality disorders.9,20 Coping mechanisms often divert the patient from mainstream medical care to pursue alternative remedies with resultant deterioration of the wound and progressive social isolation. Nearly half of our patients delayed seeking traditional medical treatment initially. Women with fungating breast masses have reported avoiding medical care due to shame, embarrassment, fear of cancer diagnosis, loneliness, and limited resources.1,2,8,9,13,17,19
The treatment algorithm for malignant wounds should be tailored to the individual patient’s needs, with the main focus of improving quality of life and reducing both psychological and physical distress. The literature supports palliative resection in patients with malodorous masses to decrease suffering and increase social and family support for the patient.18 Coordination with nursing, at-home wound care, and patient education can also assist with alleviating symptoms and easing the wound burden. Ideally, early referral to Plastic Surgery for palliative resection may help decrease ongoing suffering from painful malignant wounds.
The biggest limitation to this study is loss to follow-up. Based on pathology and patient records, we can ascertain gross estimates of who has survived versus who has expired.
Conclusion
In the era of advancing technologies and medical innovation, the benefits of palliative surgery, that helps mitigate the open wound, should not be overlooked. Improving end of life care is beneficial to the patient and families alike. As surgeons, we strive for a tangible cure, but providing palliative resection to mitigate the sequelae of fungating wounds and allow for death with dignity might be the most humane service of all.
References
15. Delmore B, Duran D. Care of Fungating Breast Wounds. Clinical Journal of Oncology Nursing. 2009;13(1):113–115. doi:10.1188/09.cjon.113–115
19. Lund-Nielsen B, Müller K, Adamsen L. Malignant wounds in women with breast cancer: feminine and sexual perspectives. Journal of Clinical Nursing. 2005;14(1):56–64. doi:10.1111/j.1365–2702.2004.01022.x
Figure Legends
Figure 1. (A) Malignant fungating breast cancer (Patient #003; Supplemental Digital Content 1). The patient was diagnosed with breast cancer seven years prior to initial consultation with Plastic Surgery. She initially refused surgery and chemotherapy and opted for homeopathic and alternative care before presenting with a fungating lesion.The patient consented to palliative resection alone. (B) 1 month following palliative resection
Figure 2. (A, B) Cutaneous infiltration of malignant fungating breast cancer affecting the chest, abdomen, right upper extremity, and back (Patient #001; Supplemental Digital Content 1). Following diagnosis, the patient underwent a right mastectomy with adjuvant chemoradiation. Seven years following initial diagnosis, she developed skin ulcerations, which she managed independently until seeking wound care 11 years later. The patient was treated with a combination of local debridement, skin substitute applications, and frequent dressing changes.
Figure 3. (A) High-grade maxillary osteogenic sarcoma (conventional type) of the right anterior and posterior maxilla (Patient #044; Supplemental Digital Content 1). Protuberant, erosive, necrotic tumor displacing periorbital structures and causing skin breakdown. (B) Following palliative partial resection with maxillary and palate reconstruction and pedicled pectoralis flap.
Tables
Table 1: Patient characteristics at initial visit.
Table 2: History and Treatment Course
Table 3: Presenting Symptoms
Table, Supplemental Digital Content 1: Summary of Malignant Fungating Wounds
Detailed outline of the diagnosis, wound characteristics, treatment course, and outcome of each patient included in the series.
